Join me as I half-ass my way through medical school, encountering all sorts of freaks (patients, classmates, myself, etc.) along the way

Friday, December 16, 2005

The Fade

I met a girl on Sunday. In the ER. Only twelve years old, she came in with some nausea, some vomiting, and a sudden inability to remember the name of her own mother. She was going to have surgery the following day to remove the recurrent tumor that had been insidiously growing inside her brain ever since her first surgery failed to remove it all nine months ago, but her parents brought her to the hospital a day early after these new symptoms scared them to the ER. Her vitals were stable, her labs within normal limits, and she was admitted to our team as my patient after an extensive workup showed nothing imminently dangerous, other than the malignancy in her brain that was going to be removed the next day.

I met a boy on Sunday, too. Also in the ER. Only four years old, he came in with a grossly swollen right eye, a fever, and an impeccable ability to kick any examining hand that came within a foot of his personal space. This eye problem had been getting worse for a few days now, did not respond to outpatient antibiotic treatment, and he was admitted to our team as my patient after an exceedingly frustrating and futile attempt at a physical exam forced us to keep him around on IV antibiotics for further monitoring because we simply could not see if his eye was affected...

On Tuesday, after a particularly good day that included a trip to the mall situated across the street from the hospital with my co-medical student (in the middle of the day no less, after informing our superiors that we were going to go study since there was clearly nothing to do on the wards), I had the privilege of speaking with one of my former interns while I was on my way home. Asked how my day went, I responded enthusiastically that it had been a fabulous day and proceeded to explain why, much like I have just explained above. The mall. A glorious lunch outside, sitting on the top of the mall overlooking the city. No patients in sight, no hassles, no notes, no screaming kids, no vitals to be checked, no orders to be written, no phone calls to be made to people who will not even listen, no boredom to be endured watching our superiors write endless notes, no lectures, no demeaning tasks to be performed, no harassment from the nurses, no scut, no worries.

Six months into my third year of medical school, after getting a taste of what my internship and residency years will be like and only beginning to appreciate the demands, the stress, and the frustration of it all, I had to admit that an exhaustion had set in and explained to my intern, albeit more briefly than what I have just expounded on here, how refreshing it was to get away, even for just a few moments.

"That's why it was so good?", she responded quite innocently. "I guess I would have figured you'd say something like 'I saw an interesting case' or 'I met an interesting patient.' "

That evening I was walking home and it was dark outside. A little cold as well. Shoving my hands in my pockets and walking briskly to make it back to my apartment, I started thinking about the tasks that lay ahead in the coming morning. More notes to write, more vitals to check, more lectures to go to, more charts to grab, more superiors to please…

It was at that moment that I realized I could not even remember the names of my patients, much less who they really were, which may not seem like a big deal were it not for the fact that I was only carrying two at the time. Yet, somehow, in spite of this I had managed to take care of all of their hospital needs up to this point.

At that moment it occurred to me that, as was subtly suggested to me that afternoon by my intern (whether intentionally or not), I had somehow fulfilled all of those mechanical needs while clearly missing the point of what I was doing there in the first place. Putting aside the exceedingly common times I have moaned about the maddening frustrations of this profession, most recently evidenced by my previous post, up until six months ago I still believed that I was clinging to those profound moments I had experienced as an undergraduate, when I was truly helping people, as the sources of my motivations for going through with all this in the first place.

Yet, somehow, in a matter of months, I had begun fading from that which I had been into what I had now become, proficient in the mechanical daily tasks of being a physician (or at least a physician's scut monkey) but having completely lost sight of the simple human picture that I had once firmly understood and promised to uphold in spite of the sheer nonsense and stupidity inherent in the first two years of medical school.

Only six months into my third year of medical school, my first sixth months as a semi-functional physician, and I had already started veering down that path of apathy, that fade into indifference that I see so many of my superiors and peers having already disappeared into. I could no longer feel the coldness of my surroundings, as I was now humbled by a frigid sense of shame I had never before felt and never wanted to feel again.

Racing back now, eager to get out of the cold and into the comfort of my bed to get my five hours of sleep, I realized that I was lucky this time, that I had someone call me out for my behavior (even if it was not done consciously), and that I was wise enough to know I was not wise enough to know better.

Utterly exhausted, frustrated, emotionally spent. A final exam in a specialty I thought I was destined to pursue, but now had serious doubts about, looming in the coming week.

But The Fade would have to wait, even if only for a day…

I met a girl on Wednesday. Only twelve years old and coming off her second brain surgery, she cried with her family before her surgery, calling out for her mother after remembering her name, and she cried heavily again Tuesday night, begging her mother to let her go home so she could be with her friends from school. Her head was swollen, and there was a huge bandage running across her forehead concealing the incision below. The radiologist confirmed that the surgeons did not get all of her tumor, that she would definitely need radiation and chemotherapy but would still likely succumb to the terror growing inside her brain. I confirmed that she had big brown eyes that spoke her of innocence and youth, that she was growing up very close to where I had lived before going to college, and that she smiled widely and brightly for me every time I walked into the room in a profound effort to keep the pain, the agony, and the uncertainty of her condition from boiling to the surface and piercing her spirit.

I met a boy on Wednesday, too. Only four years old, and his eye was no longer as swollen as it had been just two days before. His crying had long stopped, as it had been replaced by the devilish grin of a healthy four year old with a vast array of donated toys at his disposal. He gladly showed me that he could not only move his eyes without pain, but also that he could spell out his full name when I gave him a piece of paper and a crayon to write with. He showed me his train set and he even let me play with it, if only for a moment. He showed me some of the pictures he had been drawing while in the hospital, and he even gave some of them to me as a present before he left the next day, pictures now proudly displayed on my desk.

80 Comments:

This was an *amazing* post. Bittersweet and beautiful. I hope that little girl gets better...

Don't be so hard on yourself. Everyone gets caught up and loses sight of the bigger picture. Their days consist of simply going through "the process" rather than being conscious of their actions. But you realized what you were doing and that's that.

I'm a pre-med currently in the struggle to beat down the doors and get accepted. I particularly enjoyed this post. It embodied one of the biggest fears I have with medicine-- losing touch with the people you treat because you are programmed to work like a machine. I'm glad you found the reminder you needed. In my experience, the peds patients always remind me why I want to go into medicine.Keep on truckin' and keep writing :) and thanks, you reminded me too.

I stand and applaud you. Keep those pictures close at hand...better yet, fold them up and tuck them away into your wallet for one day in the future you will come across them and your mind will race back to this moment and you will find peace once again. I am so glad to read that you have had the "moment" that all med students and residents have. I can assure you that there will be more, lots more. Keep your mind, heart and eyes open to them. The smallest moment may have the biggest impact on those who come under your care.

Thats an incredible story. Your right when you say that you were lucky to have someone call you out of the beginning stages of apathy. A doctor that truely cares is worth more than his weight in gold. It's a real rarity! I really hope you become the kind of doctor you want to be, and you can forever look at the picture that little boy drew and remember why your doing what your doing.ps... best wishes to the little girl, my niece just beat brain cancer.

That was a beautiful post...I think that so long as you're consciously aware of the apathy of many of the doctors around you and critical of your own behaviour, you will be the doctor you want to be.It is truly hard when you're sleep deprived and always working to be able to see the big picture of what you're doing.

ahh doc, can't hardly call you ~fake~ anymore, that post was for real. Still wiping away the tears. You know, sometimes that's the hardest part of all, you become so close to the patients... I cried so many times , holding a forgotten old one in my arms, with no family about to care, while they breathed their last breaths.. it IS hard to care, but it's always worth it. Thank you for being one of the ones who still can care. Losing that would be something like the innocent having her virginity raped away from her....hold tight to it man, you will need it!

that's awesome! i see the same thing happening w/ my 3rd year friends.. you get so caught up in all the "scut" you kinda forget the real reason you're there... i'll definitely keep your post in mind a year from now when i'll be at the same point as you; cause all i can do now is bitch about how 2nd year sucks! keep plugging!

I find similar phenomena as a teacher. I start working mechanically and praying for a snow day (one of the big perks), and then one kid comes and gives me a hug or some crayon scribbles and makes me realize why I do what I do.

Keep those pictures forever. And sometime sit and hug that little girl, if you're allowed.

I'm going to go against the crowd and say the apathy you describe is a good thing. It is a very important self preservation mechanism- which is why you see it all around you. Its why your colleagues can still function. It took me a long time to learn it as a vet and it was not an easy lesson. You will surrender most of your time, 90% of your life and a large part of your identity to your profession. It would be stupid not to resent that on some level. Its doesn't mean you're a bad person or that you are less effective at your job despite what the happy-clappy collective would have your believe. Its necessary for your sanity. Don't be ashamed of it.

I work in healthcare too and the truth is, you never stop being there for the right reasons. There will always be periods where the patient impact doesn't hit as hard, but I have started to see it as a normal and natural part of working in an environment that is stressful, emotional, heartbreaking and heartwarming.

Once in a while I beat myself up for not remembering the patient's name or face, though their case may have had an impact on me. I spent my internship coming home and crying after long days at a children's hospital.

I still work with children, in a hospital, but rarely cry anymore. I think it might be an important coping mechanism.

Wow! You made me cry. That's awesome, the way those words moved you and got you back on the right course. They wouldn't have that effect on just anyone. As bad as you felt about the "fading", I think you should realize that you truly do have a great heart, the right heart for being a physician. I don't even know you, but I feel proud of you. May God always give you those reminders [of who you really are] and may he reward you for your hard work and compassion. Have a happy holiday!

I worked at St Jude Children's Research Hospital in Memphis for a year last year, and all I can say is that seeing a kid with cancer, especially a cancer that cant really be cured is easily one of the worst things in this world. My work involved being in a lab all day but we got glimpses of patients in the cafeterria during lunch and it was a very very harsh reality check. Sometimes it's easy to lose sight of what you're working towards, the bigger picture and all that. But seeing those paients and their families daily, sometimes hearing their stories, it gives you a sense of purpose, and you realise that the PCR that you slaved over for the past 3 weeks actually does fit into the puzzle somehow, someday.

Remember that although being jaded might help you preserve your sanity and help you to not become an emotional wreck the end of each day, being too jaded isnt too great either. I wish you all the best in finding that right balance, you seem to be doing fine:)

I'm pretty sure that you've made both those patients feel better just by talking to them. I'm also pretty sure that you've got yourself a doting admirer in that little girl. (I can't believe you made me cry)

As a vet student starting my very first clinical rotation in just a few weeks, I'm terrified of that fade you described so well. Okay, I'm terrified of a lot of things (being kicked by a horse, yelled at by a doctor), but that's one that really gets me. Because if I'm ever not excited to see a puppy, then what the hell is wrong with me?

I think that everyone has days when a trip to the mall is the best thing ever... but the fact that you recognized the creeping apathy, that you worried about it and found that sense of purpose still inside you, bodes well for your future. I only hope that six months from now, when I'm whining about endless SOAPs and early morning treatments, I can do what you did - stop, look at the child (kitten, foal, whatever) in front of me, and remember that I care.

It's easy to be apathetic towards the adults, especially after being bombarded with drug-seekers and such. It's not just limited to doctors.

However, I would think it be harder to get that way with kids. Perhaps Peds is a direction you might want to consider. Anyone can take care of grown-ups. It takes someone with a real special heart to care for the little ones.

Having been passed from doctor to doctor, and having every one, including numerous specialists, fail me, I generally don't trust doctors anymore. Nothing was more deeply discouraging than their dismissive attitudes when they couldn't find (nor be bothered to keep searching for) what was wrong with me and why I was dealing with so much pain, and their lack of empathy when it must have been obvious I was barely holding it together mentally and emotionally.

I'm glad you are trying not to lose sight of the bigger picture; there is hope that there are doctors out there who still have the ability to care. Residency will challenge your ability to remember why you are there to the extreme. There are many people who go into the profession for the wrong reasons, but if you started out with the right reasons and keep grounding yourself, you'll never lose them, and your work will be ultimately more rewarding. The medical system desperately needs more people with your ideals. Stay true to yourself.

As a patient in a large fertility clinic, I do feel annoyed that my name is forgotten, that I am just another desperate woman trying to get pregnant. I remember the day the nurse flippantly told me that my pregnancy test was negative. It's like in their haste to help as many couples towards their goals, they have lost touch with the individual heartaches and celebrations.

The positive thing about your post is that you have gained an awareness of "the fade". This self-awareness will really help you to be a great doctor!

Thank you so much for your post. I am an MSII at New York College of Osteopathic Medicine and I really loved your very well written, touching, honest and insightful entry.

Keep up the struggle against the fade. Just like that doctor had an inadvertant effect upon you, if you can make it through med school keeping that part of your humanity, you'll be be able to (both inadvertantly and purposefully) bring that to students who come your way. And that will be a service as important as the one that you provide to your patients.

Well played. Well played indeed. I read your blog often, and am glad to see a soft, convicted, and willing heart has survived this much of med school. I had a similiar experience the other day- and there is a bigger reason that should drive us both though all those boring, long, smelly days and lectures.

I think you're a better doctor than you give yourself credit for. As a patient with a chronic illness, I appreciate that there is ANY doctor who is willing to help try to treat my rare disorder. I don't want them to carry my worry and anxiety home with them. I don't want them to dwell on my case so much that it affects their day. I want them to remain healthy, alert, engaged in my health. Beyond that, everything is gravy. If they're good doctors (ie. know their stuff medically) that's really more valuable. And I think that's true for all patients.

We may grumble occasionally that a doctor doesn't seem to care but honestly, do I want someone who kisses my butt and makes nice or someone who knows their job? I want a good doctor. So don't beat yourself up about not remembering names. The odd person will stick in your mind and that's good. But I don't think you need to connect with every single patient, remember every single name, or you'll end up not being able to cope. It would be tragic to lose a good doctor because he/she put too much pressure on themselves to be perfect. Don't sweat the small stuff (eg. names) :)

BRAVO doc...As an ER social worker, I can tell you that it IS common for docs, nurses, and yes, even social workers, to start into that fade youwere talking about. It is an unfortunate, but honest occurence in every hospital across the country.I am so glad someone called you on it, perhaps now you will make a more conscious effort to try to connect with each of your patients on a more personal level. Good luck.

I'm a high school student...possibly leaning towards medicine, until I met a Doctor, head of ICU in a prominent children's hospital, talking about ethics at a workshop. I couldn't believe the apathy spewing from his lips. Totally turned me off of medicine, I didn't want to become him, you know. A jackass with an MD--so its okay to be a prat. Apathy might preserve your sanity, but there's working in the factory, and being a machine. I'd rather be a worker.

Then I read your blog, so articulate and touching...thanks for the inspiration, and reminding me there are good docs out there, even if they think they're fake.

I'm a nurse and I have to stop and remind myself sometimes that my profession is a lot about science and I love that, but the reason I went into it in the first place was for the "art" of it. It's definitely a "heart" field. To be good at it, you need both the art and the science.

Sometimes we just need to be reminded why we chose the medical field... it's easy to get lost in the routine.

I've found that taking a moment and really sitting and talking with my patients -- ignoring the beeps of the pumps, ignoring my coworkers around me, ignoring all of the world with the exception of my patient and asking them, 'No, really, how are you doing?' People appreciate the blinders and the zeroed concern.

ok i think life is cruel . what sin that little kids made .. why so much pain for those little kids (or everyone) . god must send us on earth if and only if he/she/it can give us great leaurable life not painful like this .

It's so good that those tales both seem like they'll have a happy ending.I have a good friend who was operated on for a brain tumor when he was 10. He's an amazing person who has survived a lot of problems. He had a double aneurysm 10 years ago and survived. You're doing a good job. There's nothing wrong with needing to distance yourself from your job sometimes.Peac.

I work in a hospital, of course I'm not a clinician. I'm the guy that fixes your computers and on occasion explains the problems you're having without telling you directly that you can not do this without breaking your stuff.

You're a step ahead of the game knowing that you have the potential to fade. You recognize that, and you will do it again. It's a constant test to see why you started something in the first place, especially in a field with pressure like this.

I've experienced this sort of fade in my profession, it's difficult to keep sight of purpose when production is often the order of the day.

You'll have more days like these, and if you work hard at it you'll over come them with this purpose of being. I have faith in that.

Quite the following! Keep your spirits up! A great post such as your deserves a link, an applause, and a quote, “From what we get, we can make a living; what we give, however, makes a life.” - Arthur Ashe

My mom is an RN and she's been to Nigeria on medical missions three times. The people there were EXTREMELY happy for the medical attention that she and her doctor friends were able to bring in the week-long experience. Maybe planning something like that every once-in-a-while would help "Fight the Fade" - in our country, we take our medical staff for granted, as well. I can see that affecting you as a doctor, as well.

I have been reading your page for quite some time now and I have laughed at some of your moments.

However,this post is the best one I have read because it shows the fact that you are aware of the attitude you are starting to take on . How you approached your Ah-Ha moment was sensitive,funny, and humble ,which shows how far a long your writing has come and that is great! Maybe you may want to take the picture and frame it so that you can remember the innocence of that child and compare that same innocence to the first time you came into your residency. And when you get your first office, take the framed picture as a constant reminder that even though you hear the same issues over and over again,which can become frustrating along with mundane, you know why you choose this selfless job. (or hang the picture over the seat of your favorite hiding spot!! ha-ha)

You've exposed a lot of what seems to be wrong with healthcare today... we might have the time to remember all of our patient's names if we didn't have so many! Don't be hard on yourself for not being perfect... it's perfectly impossible to do that, but it's always good to remind yourself of the positive moments in life. I like to review all of the good things in my day when it's over...You are on your way to being an amazing doctor as only you can make it that way.

good post. there are people in the medical profession who've been doing it for years and still do care. my father in law, a pediatrician - loves his job and his patients. and the nurses at st josephs childrens in tampa did a wonderful job with my cousin of 21 months who drowned and was resuscitated on dec 13. during the whole ordeal, babette was a wonderful nurse, calm, quiet, sympathetic, and straightforward. she never misled us about the gravity of the situation. crosby died on the 2nd day from cardiac arrest. but he was well-cared for by competent and kind nurses. i wish there were more people like that in the profession to surround and support grieving family members in times of tragedy.

I have a handful of friends who study medicine, once, one of them told me how an old man with no money had hurt his hand in an awful way. The fellow had no money to pay for the stitches and the pain medication... few hours later the guy showed up with chips and coke and candy for my friend, he knew she hadn't eaten anything and he didn't know how else to pay her for easing his pain.

She keeps telling me that she's not in it for the money, that there aren't millions in the world that can pay her back for all those sleepless nights, those birthdays she had to miss 'cause she had to study... but when someone is so keen in thanking you, even in such a small way, it makes her struggle much easier.

"Nurses harassing you?" Uh-oh...better change that. Take it from an ER nurse - we can be your friend or we can make your life a freaking nightmare. So as you start your residency I want you to think of those nurses you see as goddesses and treat them as such or that residency is going to be awful long.........hahahhaha (she laughs with evil delight).

wow, what a great post. great to read now..i'm a 3rd year student too and having a really tough time adjusting to it all. i think i'm actually holding on more to the ideals of being a good doctor because i haven't exactly grasped how to be "the machine" yet. not that i want to the machine but i do need to learn how to get the work done correctly and quickly. any good tips, Doc? p.s. your writing is great.